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Contents

Introduction

A bioterrorist attack, a naturally occurring
disease outbreak, or some other
large-scale public health emergency all
have the potential to result in enough
casualties to overwhelm patient care
resources.

In response to that threat,
health care organizations and systems at
the local, regional, State, and Federal
levels have taken steps to develop surge
capacity. As defined by the U.S.
Department of Health and Human
Services (HHS) surge capacity is "a health care system's
ability to expand quickly beyond normal
services to meet an increased demand for
medical care." Within HHS, the Agency
for Healthcare Research and Quality has
been assigned responsibility for
developing and assessing alternative
approaches to ensuring health care surge
capacity for mass casualty events.

Background

HHS has developed a Department-wide
strategic plan to delineate priorities and
assign responsibilities for bioterrorism
preparedness. The Office of the Assistant
Secretary for Public Health and
Emergency Preparedness (OASPHEP) is
responsible for coordinating and directing
the Department's emergency preparedness
and response programs, including
antibioterrorism efforts.

The HHS agencies with the most national visibility
in bioterrorism preparedness are the
Centers for Disease Control and
Prevention (CDC) and the Health
Resources and Services Administration
(HRSA). The National Institutes of Health
and the Food and Drug Administration
also play key roles.

AHRQ has been working steadily since 2000 to sponsor
research that provides the evidence
base for tools and resources needed for
bioterrorism planning and response.
AHRQ has funded more than 50
research projects, workshops, and Web
conferences. Based on HHS priorities,
AHRQ-sponsored research in 2004
focused on health system preparedness
for surge capacity and in 2005 focused
on mass casualty care. This Issue
Brief reviews AHRQ's research on
mass casualty care.

Planning

Health system preparedness for mass
casualty care requires exceptional
planning and coordination among
health systems at the local, State, and
regional levels. The projects described
here are major contributions to that
effort.

The tool provides an example of a methodology and includes citation of resources that are available to all States.

Supply and Staffing Options for an
Alternative Care Site is predicated on
the assumption that situations
involving mass casualties will require
either augmentation to a hospital's
patient medical resource capacity or
establishment of an alternative site for
care. Lists for three levels of supplies
are provided:

A hospital augmentation cache (50-bed unit).

A regional alternative site cache of medical supplies for a 500-bed unit.

A comprehensive cache, including equipment and supply lists, for a 50-bed alternative care site.

A table on staffing requirements for a 50-bed
alternative care site provides the
minimum number of staff required per
12-hour shift for three types of events:
infectious, noninfectious, and
quarantine.

Two other resources are appended to
the Supply and Staffing tool. One
addresses oxygen supply options. A
supply of oxygen is critical if the agent
involved affects the respiratory tract
(e.g., smallpox, anthrax, pneumonic
plague, hemorrhagic fevers, ricin). Any
possible solution to a deployable
oxygen supply, however, is both
complex and costly. This appendix
presents the issues that must be
addressed.

The second appendix is a
collection of draft gubernatorial orders
that were developed by the Colorado
Department of Public Health and
Environment to address health care
licensing and other legal issues that
would arise in the event of a mass
casualty situation.

To provide a tool that can
quantitatively predict the best choice
for an alternative care site, the Denver
Health project developed the
Alternative Care Site Selection Matrix.
This tool is available in a Web version
and an Excel spreadsheet. The Matrix
helps identify the strengths and
weaknesses of possible alternative care
sites (such as a school, stadium,
recreation center, or armory) in a
geographic area.

The fourth tool, Regional Measures of
Preparedness, takes data collected
using the Profile of Regional Medical
Resources and the Supply and Staffing
tools and compares them with
established benchmarks created by
HRSA and others.

Measures of preparedness include additional
hospital beds, medical staff,
equipment, and infrastructure. The tool
provides examples of measures and the
methodology for developing them that
can be replicated by other States and
regions.

Planning for response to a bioterrorism
event or other public health emergency must include the equipment and
facilities to accommodate the surge in
patient loads. Science Applications
International Corporation (SAIC)
developed models for personal
protective equipment, decontamination,
isolation/quarantine, and laboratory
capacity to serve as evidence-based
user tools for operational planning
based on best-demonstrated practices.

Development of each model took into
consideration factors such as:

Adaptability for use in different regions of the country and in different settings (e.g., urban vs. rural).

Cost, including supplies, logistics, and training.

Level of training required.

Resources required, including whether the model could be built using existing practices and infrastructure.

Impact on morbidity and mortality.

Regulatory compliance.

This report is available at http://archive.ahrq.gov/research/devmodels/. A common thread in the findings is
the importance of the community in
emergency preparedness. The
preparedness plan should be tailored to
the community, be communicated to
the community, and involve both the
health system and emergency providers.

The preparedness plan should be tailored to the community, be communicated to the community, and involve both the health system and emergency providers.

Building Blocks for Mass Prophylaxis

One of the first projects funded by
AHRQ in 2000 was the development
by Weill Medical College of Cornell
University of a computer simulation
model for planning a citywide response
to a bioterrorist attack. Four additional
products funded by AHRQ have grown
or are growing out of that original
model:

Bioterrorism and Epidemic Outbreak Response Model (BERM)—A companion tool to the Planning Guide, is an interactive database that allows planners to calculate the numbers of facilities and staff they will need in their communities to administer mass prophylaxis. Available at: http://archive.ahrq.gov/research/biomodel.htm

The Regional Hospital Caseload Calculator (in process)—Starts with the community's capability to administer mass prophylaxis and computes the number of people who can be reached daily with prophylaxis and the number who will become ill and require hospitalization.

Taken together, these four tools
constitute building blocks for
community preparedness for mass
prophylaxis.

Pediatric Preparedness for Disasters and Terrorism:A National Consensus Conference and Executive Summary

One concern of health system
preparedness for surge capacity is
providing care for special populations.
AHRQ has taken a lead role in funding
research for pediatric preparedness.
Children comprise approximately 25
percent of the U.S. population, and
more than 20 million of them are under
the age of six. Thus, children should be
included in any jurisdiction's
preparedness plan.

The specific elements of pediatric
preparedness were developed at a
conference in February 2003 funded by AHRQ, the Emergency
Medical Services for Children Program
in HRSA's Maternal and Child Health
Bureau, and the Phoenix Foundation.

The Execuitve Summary from Pediatric
Preparedness for Disasters and
Terrorism: National Consensus
Conference provides the first and only
set of pediatric emergency preparedness
guidelines and treatment
recommendations. The report also
includes guidance for pre-hospital and
hospital care, recommendations on training, and specific guidance
regarding numbers of equipment,
numbers of providers, actual dosages,
and treatment protocols across the
range of possible disasters, terrorism,
and other public health emergencies.

AHRQ has taken a lead role in funding research for pediatric preparedness.

Reopening Shuttered Hospitals to Expand Surge Capacity

Researchers at Abt Associates and
Partners Healthcare (Brigham and
Women's Hospital and Massachusetts
General Hospital) have developed a
guidebook on the possible conversion
of former inpatient hospitals into
temporary facilities for low-acuity
patients during a mass casualty event.
The report examines what closed
and/or converted hospitals could
potentially contribute in an
emergency; and what would need to
be done in advance to prepare to
rapidly expand a hospital's surge
capacity. Regulatory requirements and
barriers are explored in an extensive
appendix.

The report is accompanied by a Surge
Tool Kit and a Facility Checklist for
use in evaluating specific hospitals.

Training

Training has been one of AHRQ's
priorities since the beginning of its
bioterrorism preparedness program.
Two projects relevant to training for
mass casualty care are described here.

Bioterrorism and Emerging Infections Web Site

Development of this Web site at the
University of Alabama at
Birmingham was one of the first
projects funded by AHRQ in 2000.
The site offers nine online continuing
education case-based modules and
free continuing medical education
(CME) credit. The tool helps users
identify potential bioterrorist
microorganisms, and common
syndromes associated with emerging
infectious diseases or bioterrorist
agents and recognize an outbreak
resulting from bioterrorism or from
rare infectious diseases.

Evaluation of Hospital Disaster Drills: A Module-Based Approach

A critical focus for hospital disaster
planning has been the use of drills to
train employees in and to test aspects
of hospital response. Designed by the Johns Hopkins
University Evidence-based Practice
Center, the modules make it possible for planners
to identify specific weaknesses for
improvement and promote continuing
efforts to strengthen hospital disaster
preparedness. Modules cover topics
such as incident command,
decontamination, triage, and treatment.

A module on training provides
guidance on objectives, drill
preparation, evaluator training, and
other relevant issues. Pre-drill and
debriefing sections are also provided.

Response

AHRQ has also funded the
development of tools to facilitate
response capability in a mass casualty
incident.

Emergency Preparedness Resource Inventory (EPRI)

This Web-based tool developed by
Abt Associates can be used to
assemble an inventory of critical
resources for response to bioterrorism
and other emergencies. EPRI is
intended to store and routinely update
information from diverse service
providers and responders in a region,
especially a rural region, for both
planning and incident response.
Information includes available
equipment, personnel, and supplies.

The tool allows the host/administrator
to specify what types of organizations
to include, what types of resources,
how often to update, who has access
to various levels of inventory reports,
and other parameters.

Use of the application requires a
high-speed connection and a secure
Web page to ensure confidentiality of
the data. In addition to the software
tool, the application includes an
implementation report that explains
the concepts and operation of the tool
and describes lessons learned from
the pilot test in an eight-county region
in rural Pennsylvania. A technical
manual summarizes the installation
process and system functions.

Planners can use the tool to determine
the variety of resources available in
the region and to identify gaps in
those resources. Incident response
managers can use the tool to deploy
resources in response to a particular
incident. The tool and accompanying
supporting documents are available at http:/archive.ahrq.gov/research/epri/.

Health Emergency Assistance Line and Triage Hub (HEALTH) Model

One of the key components of surge
response is risk and crisis
communication: informing the public
of an emergency and of resources
available to help them. Good
communication reduces the number of
"worried well"—people presenting to
health care facilities who may not need
to be seen. This allows hospital
resources to be used more effectively to
treat those who need them the most.

The HEALTH Model report describes
how the Denver Health Medical
Information Centers determined the
requirements, specifications, and
resources needed to develop a public
health emergency contact center that is
integrated with public health agencies.

The HEALTH Contact Center
Assessment Tool assists agencies in
developing the capabilities and
functions of the HEALTH Model. This
workbook contains step-by-step
instructions for completing five
component parts:

Contact Surge Calculator—Provides a simple way to predict the volume of contacts (phone, Web site, E-mail, fax) that may be expected by a public health agency in a public health emergency.

Staffing/Resource Calculator—Provides a simple way to determine personnel needed to handle a given number of contacts, based on industry standards. This tool will help agencies understand staffing and basic resource requirements for an internal contact center or hotline.

Capital & Technology Expense Calculators—Help assess the facilities, technology, and equipment needed to handle a given number of contacts. These tools calculate the potential capital needed for resources not currently available and help agencies understand potential costs associated with an internal contact center or hotline.

Surge Options Matrix—Provides a way to assess an agency's capabilities for implementing an emergency contact center or hotline and suggests options.

National Hospital Available Beds for Emergencies and Disasters (HAvBED) System

The National Hospital Available Beds
for Emergencies and Disasters
(HAvBED) System explores the
feasibility of a national real-time
hospital-bed tracking system to address
a surge of patients during a mass
casualty event. The model is an
exportable system that allows Federal,
regional, or State command centers to
access standardized information across
the entire Nation.

The results in this report currently are
being reviewed by Federal agencies and
others to determine next steps in
making the model operational.

Altered Standards of Care in Mass Casualty Events

Altered Standards of Care in Mass
Casualty Events is the product of a
2004 meeting by AHRQ and
OASPHEP. In that meeting, experts in
the fields of bioethics, emergency
medicine, emergency management,
health administration, health law and
policy, and public health addressed the
possibility that a mass casualty event
could compromise the ability of health
systems to deliver services consistent
with established standards of care. The
full report is available at http://archive.ahrq.gov/research/altstand/.

The report's recommended action steps for planning
and implementing health care during a
mass casualty event provide a potential
framework for future research:

Develop general and event-specific guidance for allocating scarce health and medical care resources.

Develop and implement a process to address non-clinical issues related to the delivery of health and medical care.

Develop a comprehensive strategy for risk communication with the public.

Identify, analyze, and consider modification of Federal, State, and local laws and regulations that may affect the delivery of health and medical care.

Develop a means for verifying credentials of medical and other health personnel in advance and on site.

Create strategies to ensure health and medical leadership and coordination for the health and medical aspects of system response.

Continue and expand efforts to train providers and others to respond effectively.

Develop and support a research agenda specific to health and medical care standards.

Develop a Community-Based Planning Guide for Mass Casualty Care.

Identify and support States, health systems, and regions to develop mass casualty and health and medical care response plans based on the Planning Guide and to share their results widely.

Web Conferences and Issue Briefs

AHRQ has sponsored a series of Web
conferences focused on surge capacity
and mass casualty care. Each Web
conference includes presentations by
AHRQ grantees and contractors who
summarize projects in progress or
recently completed. Other
presentations are made by
representatives of other Federal, State,
and local government agencies and
grantees involved in preparations for
surge capacity and mass casualty care.